Annex. Country Progress Indicators

Transcription

1 Annex Country Progress Indicators 2

2 COUNTRY PROGRESS INDICATORS 2008 REPORT ON THE GLOBAL AIDS EPIDEMIC Annex 2 Country Progress Indicators Country reporting and data validation As of March 2008, 147 countries had reported on progress towards implementing the Declaration of Commitment on HIV/AIDS in their 2008 Country Progress Reports submitted to UNAIDS. Indicators reported were derived from the original UNGASS Declaration of Commitment on HIV/AIDS (2001). The data in the following tables reflect Country Progress Report data as well as information taken from other sources. A comprehensive data review was undertaken by evaluation specialists at UNAIDS to check national reports for completeness, accuracy and harmonization with individual indicators. UNAIDS contacted 118 countries with followup data questions. Eighty per cent of questions regarding reported data were resolved through these communications. Data issues that were not resolved as of the publication date were not included in the data analyses summarized in this report. In addition a reconciliation process took place for data reported to UNAIDS, the Global Fund to Fight AIDS, Tuberculosis and Malaria; UNICEF; the US Government s President s Emergency Plan for AIDS Relief; WHO; and Measure Evaluation (data collected through the Demographic and Health Survey programme). As a result of discrepancies identified in this reconciliation, letters were sent to UNAIDS offices in 122 countries seeking clarification and resolution of outstanding data questions. Eighty-eight per cent of these 122 countries responded with clarifying information on coverage for antiretrovirals and prevention of mother-to-child transmission, and 50% responded to questions on other indicators. Only reconciled data values were used in the analyses discussed in this report. The National Composite Policy Index (NCPI), a questionnaire that assesses progress in the development of national HIV policies and strategies, was validated through a separate process. Two evaluation specialists checked NCPI reports for internal consistency and completeness of the response. Confusing or illogical values were corrected; countries were contacted in cases of substantial missing data and multiple, non-consolidated NCPI submissions. Overall, UNAIDS contacted 34 countries to resolve data issues relating to the NCPI to which 31 countries responded. As there are over 200 data points for each country NCPI data are not included in Appendix B, but are available alongside individual country reports on the UNAIDS website. Validated data from 130 UN member states were included in the analyses summarized in this report. Data tables The following tables present data submitted to UNAIDS in Country Progress Reports, as a part of the monitoring of progress towards the Declaration of Commitment. To allow the reader to examine changes over time, where indicators and methods were consistent across reporting years, all available data from previous years are provided. Where possible the year that the data were collected was differentiated from the year of reporting. The percentages and numbers in the tables are given rounded to the nearest whole number. Some of the Country Progress Report data were still under review with countries at the time of production of this Annex. Where this is the case, it has been explicitly footnoted in the indicator data tables. Where no data are available for a particular country for a given indicator, that country has been excluded from the relevant data table. Countries may not have submitted data for 236

3 2008 REPORT ON THE GLOBAL AIDS EPIDEMIC COUNTRY PROGRESS INDICATORS a given indicator either because no data was available with which to construct the indicator according to the UNGASS definition or because the country chose not to report on the indicator as it was considered not relevant to the county s epidemic. Values printed in the table are those endorsed by countries. In some instances these values differ from those originally submitted as a result of the reconciliation process. As such, some values in these data tables may differ from those published in individual Country Progress Reports. Where there were no data reported by a country for a specific indicator but data were available from another source, such as the Demographic and Health Survey, these data were included in the tables and are not necessarily the official data provided by the national governments. Where this was the case, the data source and year were clearly noted in the indicator data table and the specific indicator definition used is described and a reference for the source provided in the Notes Section following this Annex. These tables have been compiled and produced from the various data sources by staff at UNAIDS headquarters in Geneva who cannot take responsibility for the accuracy of the data from the original source. Indicators Since the first UNGASS progress report Followup to the 2001 UNGASS: Progress Report on the Global Response to HIV/AIDS, 2003 was compiled, core indicators for reporting have been consolidated and refined in each round of reporting, in collaboration with global partners and the UNAIDS Monitoring and Evaluation Reference Group (MERG), the international standards setting group for monitoring and evaluation. Revisions made to the UNGASS indicators since the last round of reporting are summarised below (Table 1). Instructions on how the indicators were constructed are available on the UNAIDS website in the document: UNGASS Monitoring the Declaration of Commitment on HIV/AIDS: Guidelines on the Construction of Core Indicators (April 2007). In the previous round of UNGASS reporting, indicators were grouped into two categories according to the nature of the epidemic. The distinction between a generalized epidemic indicator set and a concentrated/low prevalence epidemic set has not been made for this round of reporting. This is due to the fact that epidemics do not fit neatly into simple dichotomous classifications. In 2006, for example, some countries with a generalized epidemic and a relatively high prevalence recognized that sub-epidemics in most-atrisk populations sex workers, injecting drug users and men who have sex with men were important in their epidemic and that prevention programmes for these populations were an essential element of their national response. Rightly, these countries chose to report on the indicators for these populations in addition to the generalized indicator set. For this round of reporting all countries, regardless of their economic or epidemiological status, were requested to report on all indicators, where appropriate. Countries were expected to consider each indicator in light of the individual dynamics of their epidemic. When countries choose not to report on a particular indicator, they were asked to provide an explanation as to why they chose not to report, to allow for an analysis that differentiates between an absence of data and the inapplicability of particular indicators to particular country situations. 237

4 COUNTRY PROGRESS INDICATORS 2008 REPORT ON THE GLOBAL AIDS EPIDEMIC Table 1 Revisions to the UNGASS indicators since the previous round of reporting Comments on changes National Commitment and Action Indicators Amount of national funds disbursed by AIDS spending, by financing source governments in low- and middle-income countries Definition changed National Composite Policy Index National Composite Policy Index Questions added Percentage of transfused blood units screened for HIV Percentage of women and men with advanced HIV infection receiving antiretroviral combination therapy Percentage of HIV-positive pregnant women receiving a complete course of antiretroviral prophylaxis to reduce the risk of mother-to-child transmission Percentage of most-at-risk populations who received HIV testing in the last 12 months and who know the results Percentage of most-at-risk populations reached by prevention programmes Percentage of orphans and vulnerable children whose households received free basic external support in caring for the child Percentage of schools with teachers who have been trained in life skills-based HIV/ AIDS education and who taught it during the last academic year Percentage of large enterprises/ companies that have HIV/AIDS workplace policies and programmes Percentage of women and men with sexually transmitted infections at health care facilities who are appropriately diagnosed, treated and counselled Percentage of donated blood units screened for HIV in a quality-assured manner Percentage of adults and children with advanced HIV infection receiving antiretroviral combination therapy Percentage of HIV-positive pregnant women who received antiretrovirals to reduce the risk of mother-to-child transmission Percentage of estimated HIV-positive incident Tuberculosis cases that received treatment for Tuberculosis and HIV Percentage of women and men aged who received an HIV test in the last 12 months and who know their results Percentage of most-at-risk populations who received an HIV test in the last 12 months and who know their results Percentage of most-at-risk populations reached with HIV prevention programmes Percentage of orphaned and vulnerable children whose households received free basic external support in caring for the child Percentage of schools that provided life skills-based HIV education within the last academic year Changed from transfused blood to donated blood. Added a second part to the indicator on the proportion of blood screened according to standard operating procedures and quality assurance Included children Definition changed Indicator added to core list Indicator added to core list No changes Definition changed No changes Definition changed Removed from the core indicator list; incorporated in the NCPI Removed from the core indicator list; under revision for 2010 reporting

5 2008 REPORT ON THE GLOBAL AIDS EPIDEMIC COUNTRY PROGRESS INDICATORS Knowledge and Behaviour Indicators Ratio of current school attendance among orphans to that among non-orphans, aged Current school attendance among orphans and non-orphans aged Ratio calculation no longer required Percentage of young women and men aged who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission Percentage of most-at-risk populations who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission Percentage of young people aged who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission Suggest the replacement of the two misconception questions with local versions, where appropriate Percentage of most-at-risk populations who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission Suggest the replacement of the two misconception questions with local versions, where appropriate Percentage of young women and men who have had sex before the age of 15 Percentage of young women and men aged who have had sex before the age of 15 Age range expanded Percentage of young women and men aged who have had sex with a non-marital, non-cohabiting sexual partner in the last 12 months Percentage of women and men aged who have had sex with more than one partner in the last 12 months Age range expanded, definition changed Percentage of young women and men aged reporting the use of a condom the last time they had sex with a non-marital, noncohabiting sexual partner Percentage of women and men aged who have had more than one sexual partner in the past 12 months who report the use of a condom during their last sexual intercourse Age range expanded, definition changed Percentage of female and male sex workers reporting the use of a condom with their most recent client Percentage of female and male sex workers reporting the use of a condom with their most recent client No changes Percentage of men reporting the use of a condom the last time they had anal sex with a male partner Percentage of men reporting the use of a condom the last time they had anal sex with a male partner No changes Percentage of injecting drug users who have adopted behaviours that reduce transmission of HIV, i.e. who both avoid sharing equipment and use condoms, in the last 12 months (for countries where injecting drug use is an established mode of HIV transmission) Percentage of injecting drug users who report using a condom the last time they had sex Percentage of injecting drug users who report using sterile injecting equipment the last time they injected Composite indicator divided into component indicators (part 1) Composite indicator divided into component indicators (part 2) Impact indicators Percentage of young women and men aged who are HIV infected Percentage of young women and men aged who are HIV infected No changes Percentage of most-at-risk populations who are HIV infected Percentage of most-at-risk populations who are HIV infected No changes Percentage of adults and children with HIV still alive 12 months after initiation of antiretroviral therapy Percentage of infants born to HIV-infected mothers who are infected Percentage of adults and children with HIV known to be on treatment 12 months after initiation of antiretroviral therapy Percentage of infants born to HIV-infected mothers who are infected Definition changed Remains in core set but calculated at UNAIDS/ Geneva 239

6 COUNTRY PROGRESS INDICATORS 2008 REPORT ON THE GLOBAL AIDS EPIDEMIC Challenges in monitoring most-at-risk populations Ensuring country-level representative samples and establishing a global response information system regarding programme coverage and risk behaviours for the most at risk populations presents significant technical and ethical challenges. Methods are being developed to try to achieve representative sampling of these hard-to-reach populations (e.g. respondent-driven sampling). While these methods are being refined, it is recognized that countries may not be able to attest to the representativeness of samples used for surveys of most-at-risk populations. The data from such behavioural surveillance surveys (BSS) which are often obtained from urban convenience samples in programme catchment areas, are likely to produce a bias when measuring service coverage and risk behaviours. Thus, countries were advised to report data for these indicators using the most recent survey of mostat-risk populations that has been reviewed and endorsed by technical experts within the country, such as monitoring and evaluation technical working groups or national research councils. During the global data analysis a number of methodological differences among countries were observed in the approach for data collection on most-at-risk populations. These differences mostly relate to group definitions, measurement tools and time period applied for the data collection. All recognized differences are systematically presented in the footnotes provided in the tables. On a country-level, it is important to interpret these indicator data along side the country reported NCPI, which provides an overview of the policy environment and programmatic response regarding most at risk populations in a given country, from both the perspective of the government as well as nongovernmental groups and civil society. National Composite Policy Index The NCPI questionnaire is completed through a review of relevant documents and through interviewing people most knowledgeable about the topics covered. One part 1 of the NCPI is completed by government officials, while another part 2 is completed by representatives from civil society and bi/multi-lateral organizations. The recommended consultative process for completing the NCPI aims to foster a conducive environment for inclusion of both government and nongovernment perspectives in the consolidated NCPI response submitted by the government as part of the UNGASS report. However, this is not always respected. The regional report on 2006 UNGASS data of the Caribbean noted that it is not always clear whose response prevails in case of discrepancies of opinions (Reference: Keeping score: AIDS responses in the Caribbean: a consolidated analysis based on Caribbean reports submitted to the UNGASS 2006, p.25). To ensure full independence of the government and nongovernment responses, the government in Rwanda, for example, deliberately did not participate in the consensus meeting where the civil society NCPI responses were consolidated [Rwanda UNGASS Report, 2008]. On the whole, NCPI responses provided by the government are often more optimistic than those provided by nongovernment respondents. Where available, NCPI data on both perspectives were provided throughout the report. 1 Government officials complete questions on the national strategic plan, political support, and key policies and strategies of HIV programmes. 2 Nongovernment representatives complete questions on the country s human rights context in relation to HIV; civil society involvement in the HIV response; and key policies and strategies of HIV programmes. 240

7 2008 REPORT ON THE GLOBAL AIDS EPIDEMIC COUNTRY PROGRESS INDICATORS Notes on specific indicators 1. AIDS Spending As the national and international response to AIDS continues to scale up, it is increasingly important to accurately track in detail: i) how funds are spent at the national level and ii) where the funds originate. The data are used to measure national commitment and action, which is an important component of the UNGASS Declaration of Commitment on HIV/ AIDS. In addition, the data help national-level decision-makers monitor the scope and effectiveness of their programmes. When aggregated across multiple countries, the data also help the international community evaluate the status of the global response. This piece of strategic information supports the coordination role of the National AIDS Authority in each country and provides the basis for resource allocation and improved strategic planning processes. Since different countries can choose among different methodologies and tools to monitor the flow of AIDS funding i.e. National AIDS Spending Assessments (NASA), AIDS sub-account of the National Health Accounts (NHA) and ad hoc Resource Flows Surveys the National Funding Matrix includes a spreadsheet that allows financial data from any of these three methodologies to be easily entered, reviewed and reported. A crosswalk between NASA and NHA has been achieved for the AIDS health expenditures so there is now no difference between any of these tools to track AIDS-health expenditures; NASA simply provides more detail on expenditures on activities performed outside the health system, such as social mitigation, education, justice and other activities. A similar alignment process was undertaken for the UNFPA/UNAIDS/ Netherlands Interdisciplinary Demographic Institute Resource Flows Project. The purpose of this indicator is to collect accurate and consistent data on how funds are spent at the national level and where those funds are sourced Definition: Domestic and international AIDS spending by categories and financing sources This indicator is measured using a National AIDS Spending Assessment (NASA), which documents actual expenditures classified by eight AIDS Spending Categories and by financing source, including public expenditure from its own sources (i.e. government revenues such as taxes) and from international sources: 1. Prevention 2. Care and treatment 3. Orphans and vulnerable children 3 4. Programme management and administration strengthening 5. Incentives for human resources 6. Social protection and social services (excluding orphans and vulnerable children) 7. Enabling environment and community development 8. Research (excluding operations research included under programme management). Three main groups of financing sources: 1. Domestic public 2. International 3. Domestic private (optional for UNGASS reporting). 3 In the context of resource needs estimates and AIDS Spending Assessments, vulnerable children are defined as those that have at least one parent who is alive but seriously ill (mainly because of HIV) and unable to take care of them. 241

8 COUNTRY PROGRESS INDICATORS 2008 REPORT ON THE GLOBAL AIDS EPIDEMIC 2. Government HIV and AIDS Policies National Composite Policy Index The purpose of the National Composite Policy Index is to assess progress in the development and implementation of national-level HIV and AIDS policies and strategies. The composite index covers the following broad areas of policy, strategy and programme implementation: Part A- completed by government respondents 1. Strategic plan 2. Political support 3. Prevention 4. Treatment, care and support 5. Monitoring and evaluation Part B- completed by civil society respondents 1. Human rights 2. Civil society involvement 3. Prevention 4. Care and support 3. Blood Safety The purpose of this indicator is to assess progress in ensuring a safe blood supply. The indicator applies to all countries and it is measured annually using the WHO Global Database on Blood Safety protocol. Indicator definition and components: Definition: Percentage of donated blood units screened for HIV in a quality-assured manner. Numerator: Number of donated blood units screened for HIV in blood centres/blood screening laboratories that have both: (1) followed documented standard operating procedures and (2) participated in an external quality assurance scheme Denominator: Total number of blood units donated 4. HIV Treatment: Antiretroviral Therapy The purpose of this indicator is to assess the progress of countries in providing antiretroviral combination therapy to adults and children with advanced HIV infection. The indicator is applicable to all countries and data for the numerator is collected continuously (monthly or quarterly) with the denominator estimated. Indicator definition and components: Definition: Percentage of adults and children with advanced HIV infection receiving antiretroviral therapy. Numerator: Number of adults and children with advanced HIV infection who are currently receiving antiretroviral therapy in accordance with the nationally approved treatment protocol (or WHO/UNAIDS standards) at the end of the reporting period. Denominator: Estimated number of adults and children with advanced HIV infection. Notes on Methodology: all analysis of this indicator completed for the Global Report, including quoted country figures, reflect numerators which have gone through a tri agency reconciliation (UNAIDS/WHO/UNICEF) process and denominators which have been estimated directly from the UNAIDS/WHO Reference group on Estimates, Modelling and Projections methodology (Spectrum). The reconciliation process ensured all agencies reported the same country endorsed figure which was the most recent and met the definition of people with advanced HIV currently on treatment. Every effort was made in cases of discrepancy across the three agencies to obtain approval from the country on a final indicator value. In cases where this was not possible, the country reported value has been footnoted. For data representing 2007, some countries did not report data as of December In these 242

9 2008 REPORT ON THE GLOBAL AIDS EPIDEMIC COUNTRY PROGRESS INDICATORS instances the data were projected to December to reflect a consistent time period. 4 The estimated denominators from UNAIDS/ WHO Reference group on Estimates, Modelling and Projections methodology were used for all analysis and quoted figures in the text to ensure consistency. The country reported denominators are included in Annex Prevention of Mother-to-Child Transmission In the absence of any preventative interventions, infants born to and breastfed by HIV-infected women have roughly a one-in-three chance of acquiring infection themselves. This can happen during pregnancy, during labour and delivery or after delivery through breastfeeding. The risk of mother-to-child transmission can be significantly reduced through the complementary approaches of antiretroviral prophylactic regimes for the mother with or without prophylaxis to the infant, implementation of safe delivery practices and use of safe alternatives to breastfeeding. Antiretroviral prophylaxis followed by exclusive breastfeeding may also reduce the risk of vertical transmission when breastfeeding is limited to the first six months. The purpose of this indicator is to assess progress in preventing vertical transmission of HIV Indicator definition and components: Definition: Percentage of HIV-infected pregnant women who received antiretrovirals to reduce the risk of mother-to-child transmission Numerator: Number of HIV-infected pregnant women who received antiretrovirals during the last 12 months to reduce mother-to-child transmission Denominator: Estimated number of HIV-infected pregnant women in the last 12 months All analysis of this indicator completed for the Global Report, including quoted country figures, reflect numerators which have gone through a tri agency reconciliation (UNAIDS/ WHO/UNICEF) process and denominators which have been estimated directly from the UNAIDS/WHO Reference group on Estimates, Modelling and Projections methodology (Spectrum). The reconciliation process ensured all agencies reported the same country endorsed figure which was the most recent and met the definition of HIV-infected women receiving antiretroviral drugs over the last 12 months, and thus reflect a full year. Every effort was made in cases of discrepancy across the three agencies to obtain approval from the country on a final indicator value. In cases where this was not possible, the country reported value has been footnoted in Annex 2. For data representing 2007, some countries did not report data reflecting 12 months and in these instances the data were projected in order to reflect consistent time period. 5 The estimated denominators from UNAIDS/ WHO Reference group on Estimates, Modelling and Projections methodology were used for all analysis and quoted figures in the text to ensure consistency. The country reported denominators are included in Annex Co-management of Tuberculosis and HIV Treatment Tuberculosis (TB) is one of the commonest causes of morbidity and mortality in people living with HIV, even those on antiretroviral therapy. Intensified tuberculosis case-finding and access to quality diagnosis and treatment of tuberculosis in accordance with international/ national guidelines is essential for improving 4 Method for projection all values reported that represent time earlier than December 2007 are projected taking the last two reported data points and calculating the growth per month, which is then used to project to December Method for projection all values reported that represent less than 12 month period are projected taking the number of HIV positive pregnant women on antiretrovirals per month and dividing by the number of months the data represents and multiplying by 12 months. 243

10 COUNTRY PROGRESS INDICATORS 2008 REPORT ON THE GLOBAL AIDS EPIDEMIC the quality and quantity of life for people living with HIV. A measure of the percentage of HIVpositive tuberculosis cases that access appropriate treatment for their tuberculosis and HIV is important. A number of countries chose to report on this indicator using data obtained through HIV testing programmes. These data are not comparable to data obtained through general population based surveys, and are footnoted in the data table. The purpose of this indicator is to assess progress in detecting and treating tuberculosis in people living with HIV Indicator definition and components: Definition: Percentage of estimated HIV-positive incident Tuberculosis cases that received treatment for Tuberculosis and HIV Numerator: Number of adults with advanced HIV infection who are currently receiving antiretroviral combination therapy in accordance with the nationally approved treatment protocol (or WHO/UNAIDS standards) and who were started on Tuberculosis treatment (in accordance with national Tuberculosis programme guidelines) within the reporting year Denominator: Estimated number of incident Tuberculosis cases in people living with HIV 7. HIV Testing in the General Population In order to protect themselves and to prevent infecting others, it is important for individuals to know their HIV status. Knowledge of one s status is also a critical factor in the decision to seek treatment. The purpose of this indicator is to assess progress in implementing HIV testing and counselling Indicator definition and components: Definition: Percentage of women and men aged who received an HIV test in the last 12 months and who know their results Numerator: Number of respondents aged who have been tested for HIV during the last 12 months and who know their results Denominator: Number of all respondents aged HIV Testing in Most-at-risk Populations In order to protect themselves and to prevent infecting others, it is important for members of most-at-risk populations to know their HIV status. Knowledge of one s status is also a critical factor in the decision to seek treatment. This indicator should be calculated separately for each population that is considered most-at-risk in a given country: sex workers, injecting drug users, and men who have sex with men. The purpose of this indicator is to assess progress in implementing HIV testing and counselling among most-at-risk populations. Indicator definition and components: Definition: Percentage of most-at-risk populations who received an HIV test in the last 12 months and who know their results Numerator: Number of most-at-risk population respondents who have been tested for HIV during the last 12 months and who know the results Denominator: Number of most-at-risk population included in the sample 9. Most-at-risk Populations: Prevention Programmes Most-at-risk populations are often difficult to reach with HIV prevention programmes. However, in order to prevent the spread of HIV among these populations as well as into the general population, it is important that they access these services. This indicator should be calculated separately for each population that is considered most-at-risk in a given country: sex workers, injecting drug users, men who have sex with men. The purpose of this indicator is to assess progress in implementing HIV prevention programmes for most-at-risk populations 244

11 2008 REPORT ON THE GLOBAL AIDS EPIDEMIC COUNTRY PROGRESS INDICATORS Indicator definition and components: Definition: Percentage of most-at-risk populations reached with HIV prevention programmes Numerator: Number of most-at-risk population respondents who replied yes to both (all three for injecting drug users) of the following questions 1. Do you know where you can go if you wish to receive an HIV test? 2. In the last twelve months, have you been given condoms? 3. (Injecting drug users) In the last twelve months, have you been given sterile needles and syringes? Denominator: Total number of respondents surveyed 10. Support for Children Affected by HIV and AIDS As the number of orphaned and vulnerable children continues to grow, adequate support to families and communities needs to be assured. In practice, care and support for orphaned children comes from families and communities. As a foundation for this support, it is important that households are connected to additional support from external sources. The purpose of this indicator is to assess progress in providing support to households that are caring for orphaned and vulnerable children aged Indicator definition and components: Definition: Percentage of orphaned and vulnerable children aged 0 17 whose households received free basic external support in caring for the child Numerator: Number of orphaned and vulnerable children who live in households that received at least one of four types of support for each child Denominator: Total number of orphaned and vulnerable children aged 0 17 For the purposes of this indicator and in accordance with UNICEF definitions (see reference below), an orphan is defined as a child below the age of 18 that has lost one or both parents. A child made vulnerable by HIV is below the age of 18 and: i.) has lost one or both parents; or ii.) has a chronically ill parent (regardless of whether the parent lives in the same household as the child); or iii.) lives in a household where, in the last 12 months, at least one adult died and was sick for three of the four months before he or she died; or iv.) lives in a household where at least one adult was seriously ill for at least three of the past 12 months. A number of countries chose to report on this indicator using data obtained through HIV testing programmes. These data are not comparable to data obtained through general population based surveys, and are footnoted in the data table. 11. Life Skills-based HIV Education in Schools Life skills-based education is an effective methodology that uses participatory exercises to teach behaviours to young people that help them deal with the challenges and demands of everyday life. It can include decision-making and problem-solving skills, creative and critical thinking, self-awareness, communication and interpersonal relations. It can also teach young people how to cope with their emotions and causes of stress. When adapted specifically for HIV education in schools, a life skills-based approach helps young people understand and assess the individual, social and environmental factors that raise and lower the risk of HIV transmission. When properly implemented, it can have a positive effect on behaviours, including delay in sexual debut and reduction in number of sexual partners. The purpose of this indicator is to assess progress towards implementation of life skills-based HIV education in all schools. 245

12 COUNTRY PROGRESS INDICATORS 2008 REPORT ON THE GLOBAL AIDS EPIDEMIC Indicator definition and components: Definition: Percentage of schools that provided life skills-based HIV education in the last academic year Numerator: Number of schools that provided life skills-based HIV education in the last academic year Denominator: Number of schools surveyed 12. Orphans: School Attendance AIDS is claiming ever growing numbers of adults just at the time in their lives when they are forming families and bringing up children. As a result, orphan prevalence is rising steadily in many countries, while fewer relatives within the prime adult ages mean that orphaned children face an increasingly uncertain future. Orphanhood is frequently accompanied by prejudice and increased poverty, factors that can further jeopardize children s chances of completing school education and may lead to the adoption of survival strategies that increase vulnerability to HIV. It is important therefore to monitor the extent to which AIDS support programmes succeed in securing the educational opportunities of orphaned children. The purpose of this indicator is to assess progress towards preventing relative disadvantage in school attendance among orphans versus non-orphans. Indicator definition and components: Definition: Current school attendance among orphans and non-orphans aged Part A: Current school attendance rate of orphans aged Numerator: Number of children who have lost both parents and who attend school Denominator: Number of children who have lost both parents Part B: Current school attendance rate of children aged both of whose parents are alive and who live with at least one parent Numerator: Number of children both of whose parents are alive, who are living with at least one parent and who attend school Denominator: Number of children both of whose parents are alive who are living with at least one parent 13. Young People: Knowledge about HIV Prevention HIV epidemics are perpetuated through primarily sexual transmission of infection to successive generations of young people. Sound knowledge about HIV and AIDS is an essential pre-requisite albeit, often an insufficient condition for adoption of behaviours that reduce the risk of HIV transmission. The purpose of this indicator is to assess progress towards universal knowledge of the essential facts about HIV transmission. Indicator definition and components: Definition: Percentage of young people aged who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission Numerator: Number of respondents aged years who gave the correct answer to all five of the following questions: 1. Can the risk of HIV transmission be reduced by having sex with only one uninfected partner who has no other partners? 2. Can a person reduce the risk of getting HIV by using a condom every time they have sex? 3. Can a healthy-looking person have HIV? 4. Can a person get HIV from mosquito bites? 5. Can a person get HIV by sharing food with someone who is infected? Denominator: Number of all respondents aged

13 2008 REPORT ON THE GLOBAL AIDS EPIDEMIC COUNTRY PROGRESS INDICATORS 14. Most-at-risk Populations: Knowledge about HIV Prevention Concentrated epidemics are generally driven by sexual transmission or use of contaminated injecting equipment. Sound knowledge about HIV and AIDS is an essential prerequisite if people are going to adopt behaviours that reduce their risk of infection. This indicator should be calculated separately for each population that is considered most-at-risk in a given country: sex workers, injecting drug users, men who have sex with men. The purpose of this indicator is to assess progress in building knowledge of the essential facts about HIV transmission among most-at-risk populations. Indicator definition and components: Definition: Percentage of most-at-risk populations who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission 15. Sex Before the Age of 15 A major goal in many countries is to delay the age at which young people first have sex and discourage premarital sexual activity because it reduces their potential exposure to HIV. There is also evidence to suggest that first having sex at a later age reduces susceptibility to infection per act of sex, at least for women. The purpose of this indicator is to assess progress in increasing the age at which young women and men aged first have sex Indicator definition and components: Definition: Percentage of young women and men aged who have had sexual intercourse before the age of 15 Numerator: Number of respondents (aged years) who report the age at which they first had sexual intercourse as under 15 years Denominator: Number of all respondents aged years Numerator: Number of most-at-risk population respondents who gave the correct answer to all five of the following questions: 1. Can the risk of HIV transmission be reduced by having sex with only one uninfected partner who has no other partners? 3. Can a person reduce the risk of getting HIV by using a condom every time they have sex? 3. Can a healthy-looking person have HIV? 4. Can a person get HIV from mosquito bites? 5. Can a person get HIV by sharing food with someone who is infected? Denominator: Number of most-at-risk population respondents who gave answers, including don t know, to all five questions 16. Higher-risk Sex The spread of HIV largely depends upon unprotected sex among people with a high number of partnerships. Individuals who have multiple partners (concurrently or sequentially) have a higher risk of HIV transmission than individuals that do not link into a wider sexual network. The purpose of this indicator is to assess progress in reducing the percentage of people who have higher-risk sex. Indicator definition and components: Definition: Percentage of women and men aged who have had sexual intercourse with more than one partner in the last 12 months Numerator: Number of respondents aged who have had sexual intercourse with more than one partner in the last 12 months Denominator: Number of all respondents aged

14 COUNTRY PROGRESS INDICATORS 2008 REPORT ON THE GLOBAL AIDS EPIDEMIC 17. Condom Use During Higher-risk Sex Condom use is an important measure of protection against HIV, especially among people with multiple sexual partners. The purpose of this indicator is to assess progress towards preventing exposure to HIV through unprotected sex with non-regular partners. Indicator definition and components: Definition: Percentage of women and men aged who had more than one partner in the past 12 months who used a condom during their last sexual intercourse Numerator: Number of respondents (aged 15 49) who reported having had more than one sexual partner in the last 12 months who also reported that a condom was used the last time they had sex Denominator: Number of respondents (15 49) who reported having had more than one sexual partner in the last 12 months 18. Sex Workers: Condom Use Various factors increase the risk of exposure to HIV among sex workers, including multiple, non-regular partners and more frequent sexual intercourse. However, sex workers can substantially reduce the risk of HIV transmission, both from clients and to clients, through consistent and correct condom use. Note: countries with generalized epidemics may also have a concentrated sub-epidemic among sex workers. If so, it would be valuable for them to calculate and report on this indicator for this population. The purpose of this indicator is to assess progress in preventing exposure to HIV among sex workers through unprotected sex with clients. Indicator definition and components: Definition: Percentage of female and male sex workers reporting the use of a condom with their most recent client Numerator: Number of respondents who reported that a condom was used with their last client in the last 12 months Denominator: Number of respondents who reported having commercial sex in the last 12 months 19. Men Who Have Sex with Men: Condom Use Condoms can substantially reduce the risk of the sexual transmission of HIV. Consequently, consistent and correct condom use is important for men who have sex with men because of the high risk of HIV transmission during unprotected anal sex. In addition, men who have anal sex with other men may also have female partners, who could become infected as well. Condom use with their most recent male partner is considered a reliable indicator of longer-term behaviour. Note: Countries with generalized epidemics may also have a concentrated sub-epidemic among men who have sex with men. If so, it would be valuable for them to calculate and report on this indicator for this population. The purpose of this indicator is to assess progress in preventing exposure to HIV among men who have unprotected anal sex with a male partner. Indicator definition and components: Definition: Percentage of men reporting the use of a condom the last time they had anal sex with a male partner Numerator: Number of respondents who reported that a condom was used the last time they had anal sex Denominator: Number of respondents who reported having had anal sex with a male partner in the last six months 248

15 2008 REPORT ON THE GLOBAL AIDS EPIDEMIC COUNTRY PROGRESS INDICATORS 20. Injecting Drug Users: Condom Use Safer injecting and sexual practices among injecting drug users are essential, even in countries where other modes of HIV transmission predominate, because: (i) the risk of HIV transmission from contaminated injecting equipment is extremely high; and (ii) injecting drug users can spread HIV (e.g. through sexual transmission) to the wider population. The purpose of this indicator is to assess progress in preventing sexual transmission of HIV Indicator definition and components: Definition: Percentage of injecting drug users reporting the use of a condom the last time they had sexual intercourse Numerator: Number of respondents who reported that a condom was used the last time they had sex Denominator: Number of respondents who report having had sexual intercourse in the last month 21. Injecting Drug Users: Safe Injecting Practices Safer injecting and sexual practices among injecting drug users are essential, even in countries where other modes of HIV transmission predominate, because: (i) the risk of HIV transmission from contaminated injecting equipment is extremely high; and (ii) injecting drug users can spread HIV (e.g. through sexual transmission) to the wider population. Note: countries with generalized epidemics may also have a concentrated sub-epidemic among injecting drug users. If so, it would be valuable for them to calculate and report on this indicator for this population. The purpose of this indicator is to assess progress in preventing injecting drug use-associated HIV transmission. Indicator definition and components: Definition: Percentage of injecting drug users reporting the use of sterile injecting equipment the last time they injected Numerator: Number of respondents who report using sterile injecting equipment the last time they injected drugs Denominator: Number of respondents who report injecting drugs in the last month 24. HIV Treatment: Survival After 12 Months on Antiretroviral Therapy One of the goals of any antiretroviral therapy programme is to increase survival among infected individuals. As antiretroviral therapy is scaled up in countries around the world, it is also important to understand why and how many people drop out of treatment programmes. These data can be used to demonstrate the effectiveness of those programmes and highlight obstacles to expanding and improving them. The purpose of this indicator is to assess progress in increasing survival among infected adults and children by maintaining them on antiretroviral therapy. Indicator definition and components: Definition: Percentage of adults and children with HIV known to be on treatment 12 months after initiation of antiretroviral therapy Numerator: Number of adults and children who are still alive and on antiretroviral therapy at 12 months after initiating treatment Denominator: Total number of adults and children who initiated antiretroviral therapy who were expected to achieve 12-month outcomes within the reporting period, including those who have died since starting antiretroviral therapy, those who have stopped antiretroviral therapy, and those recorded as lost to follow-up at month 12. Revisions were made to this indicator to reflect minimal survival only. For this reason the indicator may reflect lower survival rate than the maximum survival definition which excludes individuals who stopped antiretroviral therapy, died, or were lost to follow-up. In cases where it is known a reported data value is not reflecting this definition, this information has been footnoted in the annex tables. 249

16 COUNTRY PROGRESS INDICATORS 2008 REPORT ON THE GLOBAL AIDS EPIDEMIC All analysis of this indicator completed for the Global Report, including quoted country figures, reflect numerators which have gone through a bi agency reconciliation (UNAIDS/WHO) process. The reconciliation process ensured all agencies reported the same country endorsed figure which was the most recent and met the definition of minimum 12 month survival of one cohort. Every effort was made in cases of discrepancy between the two agencies to obtain approval from the country on a final indicator value. In cases where this was not possible, the country reported value has been footnoted in Annex 2. Caribbean Haiti Cuba Dominican Republic Jamaica Dominica Grenada Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines East Asia Mongolia China Eastern Europe and Central Asia Countries that provided reports on the implementation of the Declaration of Commitment (n=147) High income Antigua and Barbuda Barbados Bahamas Cyprus Estonia Israel Qatar Slovenia Trinidad and Tobago Australia Belgium Canada Switzerland Germany Spain Finland United Kingdom of Great Britain and Northern Ireland Greece Ireland Japan Netherlands New Zealand Sweden Kyrgyzstan Tajikistan Uzbekistan Armenia Azerbaijan Bosnia and Herzegovina Belarus Georgia Moldova Ukraine Bulgaria Croatia Kazakhstan Lithuania Latvia Romania Russian Federation Latin America Bolivia Colombia Ecuador Guatemala Guyana Honduras Nicaragua Peru Paraguay Suriname El Salvador Argentina Brazil 250

17 2008 REPORT ON THE GLOBAL AIDS EPIDEMIC COUNTRY PROGRESS INDICATORS Belize Chile Costa Rica Mexico Panama Uruguay North Africa and Middle East Sudan Algeria Jordan Morocco Tunisia Lebanon Turkey Oceania Papua New Guinea Fiji Micronesia, Federated States of Marshall Islands Tuvalu Palau South and South East Asia Afghanistan Bangladesh India Cambodia Lao People s Democratic Republic Nepal Pakistan Viet Nam Indonesia Iran, Islamic Republic of Sri Lanka Philippines Thailand Malaysia Sub-Saharan Africa Burkina Faso Burundi Benin Democratic Republic of the Congo Central African Republic Côte d Ivoire Eritrea Ethiopia Ghana Gambia Guinea Guinea-Bissau Kenya Comoros Madagascar Mali Mauritania Malawi Mozambique Niger Nigeria Rwanda Sierra Leone Senegal Somalia Sao Tome and Principe Chad Togo United Republic of Tanzania Uganda Zambia Zimbabwe Angola Congo, Republic of the Cameroon Cape Verde Lesotho Namibia Swaziland Botswana Gabon Mauritius Seychelles South Africa Western and Central Europe Albania The former Yugoslav Republic of Macedonia Hungary Montenegro Poland Serbia 251

18 COUNTRY PROGRESS INDICATORS 2008 REPORT ON THE GLOBAL AIDS EPIDEMIC UNGASS indicator 1. Country Reports of Domestic and International AIDS Spending by service categories and financing sources. Region/Reporting Country Caribbean Total reported Domestic Public and International Expenditure (Million US Dollars) Domestic Public (%) Bilaterals (%) Share by financing source Global Fund (%) International Multilaterals UN and all other Multilaterals (%) All other international sources or not specified (%) Total HIV Expenditures in selected services (Million US Dollars) Total for Prevention Prevention Year of the expenditure Communication for social and behavioral change Voluntary counseling and testing Antigua and Barbuda 2006 $ % 25.4% 8.7% 0.0% 0.0% NA/NR NA/NR NA/NR Antigua and Barbuda $ % NA/NR NA/NR NA/NR NA/NR NA/NR NA/NR NA/NR Aruba $ % NA/NR NA/NR NA/NR NA/NR NA/NR NA/NR NA/NR Aruba $ % NA/NR NA/NR NA/NR NA/NR NA/NR NA/NR NA/NR Aruba $ % NA/NR NA/NR NA/NR NA/NR NA/NR NA/NR NA/NR Bahamas $ % NA/NR NA/NR NA/NR 28.4% $0.005 NA/NR NA/NR Barbados $ % NA/NR NA/NR NA/NR 2.0% NA/NR NA/NR NA/NR Cuba 2007 $ % 0.0% 19.1% 0.0% 0.0% $6.385 $5.584 $0.801 Dominican Republic $ % NA/NR NA/NR NA/NR 56.0% $4.121 NA/NR NA/NR Grenada $1.050 NA/NR NA/NR NA/NR NA/NR NA/NR NA/NR NA/NR NA/NR Haiti 2006 $ % 67.3% 24.0% 6.50% 1.55% $ $1.882 $3.427 Jamaica 2005 $ % 5.8% 39.7% NA/NR NA/NR NA/NR NA/NR NA/NR Jamaica 2006 $ % 5.2% 28.9% NA/NR NA/NR NA/NR NA/NR NA/NR Jamaica 2007 $ % 2.0% 35.5% NA/NR NA/NR NA/NR NA/NR NA/NR Saint Lucia 2006 $ % 0.0% 7.8% 46.7% 24.10% $0.604 $0.105 $0.014 Saint Lucia 2007 $ % 0.0% 13.9% 64.6% 0.0% $0.446 $0.202 $0.042 Trinidad and Tobago 2006 $ % 0.0% 0.0% 4.4% 0.0% $5.626 $3.218 $0.118 Turks and Caicos Islands Turks and Caicos Islands 2006 $ % NA/NR NA/NR NA/NR NA/NR NA/NR NA/NR NA/NR 2007 $ % NA/NR NA/NR NA/NR NA/NR NA/NR NA/NR NA/NR East Asia China 2006 $ % 4.6% 17.5% 0.8% 0.0% $0.927 $0.927 NA/NR China $ % NA/NR NA/NR NA/NR NA/NR $ $ $0.897 Japan 2006 $ % 0.0% 0.0% 0.0% 0.0% $4.130 NA/NR NA/NR Mongolia 2007 $ % 23.6% 36.0% 19.2% 14.0% $1.946 $0.179 $0.184 Eastern Europe & Central Asia Armenia 2007 $ % 7.3% 55.7% 20.8% 0.0% $1.296 $0.101 $0.197 Azerbaijan 2007 $ % 0.0% 34.3% NA/NR 0.0% $0.851 NA/NR $0.851 Belarus 2006 $ % 0.0% 28.53% 2.25% 1.03% $9.745 $0.491 $0.977 Bulgaria 2005 $ % 0.0% 57.71% 6.89% 0.0% $3.758 $0.336 $0.627 Bulgaria 2006 $ % 0.0% 43.0% 8.2% 0.0% $3.114 $0.440 $0.491 Bulgaria 2007 $ % 0.0% 43.4% 5.9% 0.0% $2.877 $0.418 $0.552 Croatia 2006 $ % 0.0% 23.0% 2.3% 0.9% $3.743 NA/NR $0.442 Georgia 2006 $ % 19.3% 56.5% 13.3% 0.0% $2.563 $0.058 $